Treating Obesity Is Treating the Brain | Dr Elizabeth Kazarian

0:03So that's how you start your day? That's how I start my day is with a fluid stack. Of water? Which is what we should popularize that. Yeah. What's a fluid stack? A fluid stack is a well-varied assortment of drinks and no specific brands. I'm open to a brand deal though for a fluid stack. And water is central. I feel like we have so many fluids on this table right now that people will just assume that these are sponsored, but they're not. They're not sponsored, but would love. La Colombe, do I say it like that? I'm not sure. Coffee, and coffee is there as well. Anyway, that all came from, I made a lot of content with like, what's your fluid stack?

0:45Because of peptide stacks, right? People love a stack and a protocol. Yes, people love those words. They love to use those words. They love to make content with those words. Do you find, do your patients think it's unusual that a doctor drinks Diet Coke or does anyone, does anyone question you about that? Yeah, yeah, sometimes I love it. No, they are confused and I love it so much. So where do I go with that? Is that I don't drink it for any nutritional source. I'm not drinking it to replace free water. I'm drinking it because I enjoy it and my brain enjoys that dopamine hit from that non-nutritive sweetener that has zero calories.

1:29So in the world of harm reduction, Diet Coke is perfectly fine for me. What are the main myths or misconceptions you think that exist related to diet drinks with artificial sweeteners or sweeteners that don't have calories? People love to hang on to the observational studies. And it's actually so silly how many observational studies that I've read surrounding diet soda. Because when people say something like diet soda makes you fat or diet soda makes you gain weight, you have to be able to know how to dispel that. Or diet soda causes metabolic disease. You have to be able to know how to dispel that.

2:06And that's actually like learning the studies that they're using. and they're mostly observational studies where we're studying people who have already, you know, developed metabolic disease and maybe diet soda is the best thing that they're currently drinking or the best decision that they're currently drinking, but we're honing in on the diet soda and that's called reverse causality. So it's not true if someone has heard this, that the artificial sweeteners still spike insulin and lead to weight gain? No. Non-nutritive sweeteners don't have any, doesn't have glucose in it. Like that doesn't, it doesn't trigger an insulin spike.

2:40I don't know why people think that. Why do people say that online, that diet soda causes an insulin spike? I don't know why people say that. It's so easy to look up. I don't know the origin of that, but I definitely have seen people posting about it. And in addition to artificial sweeteners, messing up gut microbiome and being harmful in other ways. But you don't have any causative of data to say that. And you don't have, and like, you know, we like to make content about sensational things. We're making content about sensational headlines. And the diet or aspartame, actually not diet soda, it's aspartame that people like to hone in on for diet soda, being in the who IARC carcinogen group to be carcinogen group.

3:26But so is, you know, pickled vegetables, which people say that fermented foods have a gut microbiome benefit now they're in the same cancer category together what do we do with that information well that all comes down to nuance yeah i mean the microbiome research in and of itself that's a big rabbit hole because even even the fermented food studies like one of the big ones and i've spoken about it on this show it the outcomes that are measured were things like changes to microbiome diversity and that as an outcome, it associates with like good health, but it's not a proven kind of, there's not a proven causal model there.

4:06We haven't shown that manipulation of the microbiome to make it more diverse leads to some health benefit. There's a big assumption there. I love this topic, which is like a big wellness topic, which is like people honing in on specific things like your mitochondrial health, right? Or like people going in on mitochondrial health. Well, we're not treating organelles and cells. We're treating humans with conditions. And we haven't proven that saying this is beneficial for your mitochondrial health. We haven't proven that leads to a measurable health outcome. The problem is it sounds very sciencey and very compelling.

4:38So to someone who isn't kind of trained in science and doesn't necessarily understand that a mechanism in a petri dish or in an animal study doesn't always translate and usually doesn't translate to a human model. I am not a mouse. Yeah. It can be very engaging and exciting. And so I think that kind of biohacking space and zooming in on a particular mechanism and kind of over extrapolating, the reason that people fall into that trap is because as an influencer, when you do that, you get lots of clicks. You get lots of engagement. But how are you doing that when you have a PhD? Like, aren't you embarrassed?

5:20Well, I think that you should have pride in doing the right thing by your audience. Yeah. If you're building an audience based on trust and you have an MD or a DO or a PhD behind your name, that comes with a lot of public trust. Inevitably, there's a lot of honor in carrying that degree. I think that honor is changing in that. So in decades gone by, you'd get your PhD or your MD, you'd do your residency, you'd go and get board certified, things that you've done and you'd be out there treating patients. A lot of people today are doing their PhD and even their MD, not doing a residency, going straight out of getting the PhD, just straight to online content.

6:01And the kind of credentials next to their name are more for marketing purposes. That's crazy to me. I'm just terrible at marketing, I guess, because I became a physician in training, like in going through residency, going through that process. I was so passionate as a resident when I started making content at first about what it's like going through this. Like it's like a rite of passage almost. And I've talked to Terry Simpson about this and I got to bond with him at the figs retreat. And hey, Terry, you're awesome. And he's a surgeon. And there's just this long training that you put years and years into because you love it.

6:40And there's honor there. And anyone else who's gone through it respects it so much. There's this mutual professional community where you look at each other and like you can understand that. And that's why there's this rise of physicians posting online because there have been physicians who completely skipped that part and just created online presences and build business empires. Like, honestly, I'm not here to like put down entrepreneurs, but what like it doesn't make you a good physician if you don't go through the training and then you're going to have an online presence and preach protocol philosophy.

7:11So when you say don't go through the training, what do you think is the bare minimum training in order to actually be a medical doctor online that understands the evidence, understands patient care, understands patient experience? I think that it finally clicked when I felt like I could lead a medical team myself as a PGY3. What's a PGY3? So you finish medical school and then you have an MD behind your name, which I think is wrong. That allows for the loophole of someone to skip training. I want to explore that more. When you say someone finishes medical school, that's when they get the MD. You get those initials next to your name.

8:01So at that point, what's the minimum number of years that someone might have studied to get that? High school, undergrad and medical school. So still eight years or six or eight years of study. Yeah. But I wouldn't say that the undergraduate study in the U.S. is necessarily geared towards medicine enough where that encourages me or makes me feel, oh, great, you did college. Okay, great. Right. And would you say up to that point, getting those initials, is that more testing your ability to kind of read textbooks and perform on exams versus patient, true patient care? I think you get patient care third year of medical school and fourth year when you hone in on your electives.

8:47But true patient care is when you are an intern yourself. Is that residency? That's residency. And first year for everyone is called intern year. And that is when you are, you're around, you're pre-rounding on the entire list of patients. It's inpatient medicine. The acuity is higher. The conditions you're treating are, you know, it's critical. It's really intensive learning period. And it's really important to go through. What did your residency look like? I was heavily inpatient medicine at the University of Virginia. I had a really good training. I had to rotate through lots of different specialties within UVA health system because that's how you become the best family doctor is you know a little bit about everything.

9:32And we had to do a lot of cardiology inpatient, which I think was actually really great and lends itself to becoming a better outpatient family doctor. and we were an FM OB program. So I was also delivering babies. So overnight float, delivering babies upstairs, labor and delivery, watching fetal heart monitor strip, getting a page that I need to admit someone downstairs in the emergency room, asking one of my OB friends, hey, can you watch my strip really quick? I'm gonna go downstairs. It's a type two end stemmy. They're not gonna go to cardiology. I'm just gonna put them on a heparin drip and I'm gonna come right back upstairs.

10:02And are you getting, you're kind of being supervised by a more experienced physician? No, they're at home. Okay. they're sleeping at home and you call your attending you're okay i have an admit they're like that sounds a bit scary and they're like okay sounds good that sounds a little bit scary or they don't answer and they like call you back later but at that time of your experience you have enough experience to be able to handle all that night float by yourself starts second year so if you're a third year you've been doing it now for two years should be able to um except for when we were delivering babies there's always an attending always there was always that but when you're admitting straight medicine patients now.

10:41Is that in Norfolk University of Virginia? It's in Charlottesville. Charlottesville. Yeah. My dad, I actually lived in Virginia as a kid. My dad, my dad's a professor of physiology now at a different university, but he used to work at University of Virginia. Oh my gosh. Yeah. So in Charlottesville. Yeah. So go into the, his lab and like when I was like a little kid and wear his lab coat. Oh my God, I love that so much. That's so cool. At UVA? Yeah. Oh, that's so awesome. Yeah. Small world. Yeah. There's such a small world. Today's episode is brought to you by Shox and specifically their OpenFit Pro, which I'm wearing right now.

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12:33This code can and be combined with all other official promotions. You finished residency. I know now you're board certified in family medicine and in obesity. Yeah, yeah, yeah. So what prompted you to continue to torture yourself with more study? No, literally. And also, I'm not the type to want to. That's not my personality type. I go get board certified because I think it's absolutely necessary to prove to my patients that I know what I'm doing and to instill trust in them. Um, so I found obesity medicine because I am a family physician. So through training, it becomes just kind of like illness scripts.

13:13You're learning how to take care of like beyond just the bedside manner and treating the actual person in front of you is like learning how to treat certain conditions and learning illness scripts. And I saw the same ones over and over and over again. Illness scripts. So when you're in residence or you're going through training, especially if you're going through primary care training or internal medicine training you start to learn you know what do we do for cirrhosis what do we do for bacterial pneumonia you know if someone's coming from the icu versus coming from the community you just like learn certain kind of scripts for certain things and when it came to primary care in the united states it was always like sleep apnea arthritis joint pain all these things downstream of obesity Functional limitations, 20 years of up and down and weight, 100 pounds, trying to be on a diet since they were eight years old, A1C, like actual A1C numbers, A1C concerns, blood pressure, liver enzyme elevation, steatosis on ultrasound.

14:15You know, all of these downstream conditions that we're treating individually, but if you look just upstream, having compassion to talk about actual obesity in the room with a person in front of you, saying the word obesity, that is not an insult. There's some sort of idea on social media that the word carries some kind of negative connotation, but obesity is a word. It is a medical condition that is recognized by the AMA. we don't say the word fat we don't like saying f it's the f word we need to start you know being more sensitive about that there's a lot of content creators that are not using sensitive enough language and where do i get this from my patients they teach me everything they tell me what is offensive what is not what it's like to live in a bigger larger body um you know we all have our own health journeys.

15:10I have PMOS and I actually use that to relate to my patients. And one of the driving background processes in PMOS is insulin resistance. And so there's a lot of things we can relate to with our patients, but when it comes to understanding someone who has struggled with obesity with their whole life, your job as a family doctor, as an obesity medicine doctor, is to listen to them and what has been their life experience. So your experience as a patient, and P-M-O-S is the new terminology for PCOS. Yeah, yeah, yeah. That's given you more empathy? It does, totally. I think being a doctor has made me a more empathetic person overall because if you don't have the experience of actually treating tons of people every single day and just like your job is to listen to people, how are you supposed to know why they're not following your guidance or why they didn't come to their appointment last time?

16:16But the beauty in family medicine is the longitudinal relationship. And so you'll be able to see them next time and they'll explain to you that, you know, their single mom and childcare didn't work out, things like that. Presumably then it must really frustrate you when you see language that induces shame because you're seeing the shame in the clinic. Or like Donald Trump calling the shots the fat shot. No, literally. Yeah, yeah. Just calling it the fat shot, which is like, oh, it just hurts. Like it just physically hurts when you come across media from the highest level of leadership, which, you know, used to be an automatically respectable position.

16:54And, you know, has only I've only changed my mind about that, given what that person has chosen to behave or how they've chosen to behave. But no, so stigma coming from all around them constantly their whole lives and the breakdown that I have the honor to see or like the trust that we've developed and they're, you know, opening up to me in clinic and then seeing what they're actually up against out there in social media. It's crazy. What would you say to someone who hears this conversation around shame and language and thinks we're being too soft? We call it body fat. It's a name for a tissue in the body and this is just a little bit woke, an overreaction to being too sensitive to something like the fat shot.

17:49Well, I just think, no, they're just wrong because I'm kind of a hard ass and I have tough love in clinic and I think my patients appreciate it. And I still think that you need to lead with empathy. That's how you get people to change. That's how you get people to heal. You don't lead with shame or making, I don't know, you don't lead with embarrassment. You don't lead with even, you know, touching on someone's character. This is a medical condition. The fact that we're even making any comments or statements about their character is insane. We don't do that with any other health condition. And I think this happens because obesity is, of course, directly tied with our identity, our physical outward identity.

18:30And I also think that's why GOP-1s have completely shaken up our society. We don't have another medication in the media like GLP-1s, right? It's because it's totally shaken the core of our identity, which is our outward appearance. All of a sudden, people can lose weight and take the easy way out. I read a report recently. I think 11 % of U.S. adults report that they're using a GLP-1 medication today. And that was maybe 3 % or 4 % a couple of years ago. some reports are forecasting that number will exceed 20 % based on access by 2030, so just a few years away. So it sounds like you see that as a medical breakthrough as opposed to rapid medicalization that would be a cause for concern.

19:18Yeah, well, 40 % of our country has obesity and that's getting into the conversation of who deserves treatment. If you have obesity, you deserve treatment. Obesity is diagnosed by history and also clinically by body fat percentage. And so if you, you know, if it's medically indicated, then what's to say that that person doesn't deserve treatment? And if 40 % of our country meets criteria, why doesn't everybody deserve treatment? I think some people that hear those statistics would be concerned that it's it's covering up a larger problem the problem of the food environment socioeconomic disparity sedentary lifestyles and and perhaps asking a question are we are we rushing to medicalize everyone and not challenging parts of our system that require more regulation and new policies.

20:19It all has a place and it all needs to happen all at once. I don't know if that was the answer you're looking for, but what I know is that my patient's lives are at risk now. Like my patient's going to live a shorter life now. They've had obesity since they were a child and now they're 40, right? So this person has been waiting and living 40 years and looking for a solution and their country has failed them. And we're taking system issues, like you brought up the food environment, that's going against big food, right? That's going against big money. So we're taking these systemic societal problems and replacing individual blame on people and we're calling them lazy, which is insane.

21:01And back to the, you know, you saying, well, what if, what about the people who are saying that we're being too sensitive? Well, look at the biggest loser. Look at the way Jillian Michaels talked to people. That didn't work out. The people that won that TV show regained weight. There were medical emergencies on that TV show. There was something about caffeine pills. They did try to use pharmacotherapy. They probably didn't feel too good about themselves either. No, you're getting, what is going on here? Since when is like lowering someone's self-esteem in medical care. No. The person who uses that tactic is not a clinician.

21:37The person does not take care of human beings. I agree with you. I think totally that the environment, it needs to change, but it's going to take time. Yeah. And my patient's going to die. My patient has type 2 diabetes and chronic kidney disease and MASH and obesity now. I need a medical solution now. What are you seeing in clinic with the prescription of GLP-1 medications? How is it affecting the lives of patients? So I think what the internet sees is the widespread use of them. And what I see in clinic is the medical necessity or the medical use of them. And so... What's the distinction there?

22:20There has been a market created through telehealth companies where it's been marketed online. I mean, look at... just the commercials. There's no physician or clinic or anything medical in sight in the commercial. This person is an attractive athlete and they're taking a GLP-1 and you can get it online delivered to your house. I think I know which athlete you're talking about. Yeah. So like that is the lifestyle side of GLP-1s, which I'm not a part of at all, right? And you barely need to, as someone going through that program, as I understand it, you barely, you don't even really need to see a physician.

22:54I know they have a physician sign off on it. Yeah, no, literally. And they automatically uptie treat the doses every month if you want to. People are at home just injecting on their own without physician oversight, just giving these telehealth companies their money. It's been a goldmine. Do you think there are people that are going through telehealth that are contraindicated or wouldn't otherwise be indicated? Potentially. Like potentially who are of normal body weight and they're, and which happens to me all the time, by the way, I say no to prescriptions all the time because I'm treating obesity, which is a condition, right?

23:24I'm not a weight loss doctor handing out prescriptions. It's not what I do. I practice obesity medicine. Do you treat in a telehealth setting? I love telehealth. I love it. It overcomes so many barriers to access to care. I do love it so much. There's something about doing a physical exam, getting your hands on a patient, but I do think that telehealth is part of the future that came with the COVID pandemic for sure. So you're seeing patients every day through telehealth? Yeah, sometimes it's through telehealth, but most of the time it's in person. Got you. It's in clinic. How many patients would you roughly see a day?

23:5520, 10 in the morning. And what percentage of those patients, I mean, given that you're a specialist in obesity, I'm guessing there's a kind of selection bias that most of these patients are coming to you because of obesity. Yeah, there's no template to it, but it's more self-selecting. And now it's like at least 60 % obesity medicine. And what percentage of the 60 % that fall underneath obesity medicine would be candidates for GLP-1 medication? for the people that come for kind of you know an obesity medicine evaluation oftentimes that visit ends and we have decided you know through the evidence that we have that the person doesn't have obesity and they came there to ask for a gpl1 medication and that's where you have to lead with empathy because they're not mutually exclusive right so i can still make them feel heard and get to the bottom of what is it that you're actually asking for.

24:55Because instead of asking for a GLP-1, maybe they're actually concerned about the weight gain they just had because they're going through menopause. And then we have a menopause conversation. Maybe they're asking me for a GLP-1 and I immediately explain to them, well, GLP-1s, they alter your hunger and they decrease your food intake. And then they tell me, well, I don't really feel like I even eat that much. And we go through what they eat and they don't actually eat that much. And it, you know, it turns into a different conversation. So not everybody walks out automatically with a GLP-1 prescription.

25:30When you say they might come into your clinic and then you find out they're not actually obese, is that based on like BMI body fat or is that also looking at like HbA1c and blood glucose and these other metabolic markers and saying, you know, your metabolic health appears to be okay, perhaps despite some excess. Yeah, yeah. Here's the difference between textbook way you're supposed to practice and the most optimal way of diagnosing people with obesity. And here is how it's actually being done across the United States, given the resources that are actually available. Okay. Unfortunately, we are operating in a BMI structure.

26:17It's terrible. Insurance companies are creating hard cutoffs completely based on BMI to secure eligibility for GLP-1 medications. So if you don't have a BMI of 30, you cannot apply for the Medicare Weight Loss Bridge Program. Yet we know that sometimes people develop poor metabolic health at lower BMIs. Exactly. Especially different races. Exactly. Which was on my board exam. And that's not something that is being honored by insurance companies at all. The way I practice medicine is not honored by insurance companies at all. That seems wild that they don't use different cutoffs, even like, for example, for Southeast Asians.

27:03No, they don't. But on my American Obesity Medicine Board exam, that was on my boards, you know, using 23 and 27. But the insurance company doesn't care about that. I have written a letter for a patient that had six, history of six different kinds of cancers that you can link to obesity. And she still didn't qualify for a GLP-1 medication. So insurance and the application for insurance is a big part of your practice because these medications are so expensive? Primary care physicians are inundated with administrative work in the U.S. All we do is prior authorizations and letters and appeals to try to fight to try to get these medications into our patients' hands.

27:51Writing the prescription is the easiest part of practicing obesity medicine. Trying to actually get that prescription into your patients' hands is a whole saga. Is this why the telehealth companies then, there's a big market for the companies that are offering compounded versions because they are cheaper? Yeah, because it was on the FDA shortage list and that's why they were allowed to even compound it, right? And so now it's off the FDA shortage list. They're not allowed to compound it, but it's little fires everywhere. And Eli Lilly is just going after compounding pharmacies individually. But initially they were allowed to compound the GLP-1s.

28:26I think there's a loophole. I don't know if I am 100 % accurate here. So fact check this. But I read, because I was interested how they're continuing to compound them despite that regulation. And it seems that if they add a few things to it, so if you add like glutathione or vitamin B12 to the trisepatide, then you can kind of get around that rule. Totally. And they're compounding vitamin B12 with terazepatide. It's insane. And you can't take one chemical that we think is safe and another chemical that we think is safe and just put them together and think that there might not be an interaction.

29:07That is so naive. That is so dangerous. And he literally also came out with a statement that there have been adverse reactions. So that's potentially an issue. But is there a side of you, knowing that some of your patients can't access these for affordability purposes, is there a side of you that does like the fact that compounded versions exist for a population of patients in America that would otherwise not be able to use them? Yeah, part of me likes that. I would never necessarily encourage my patients to go get compounded GLP-1s. I just, it's not that I think all compounding pharmacies are terrible and like have terrible safety standards, but they don't go through the same like pre-safety approval process that the FDA approved drugs do.

29:56They just simply don't. It's not the same. I don't know why people have so much confidence about that. They just don't. And I can't sit across from a patient with a good heart and integrity and say that this is safe for you to use. I can't. so that's why lily direct that's why the pharma the direct to consumer pharmacies are the best thing that have ever happened to obesity med by the way when it comes to access like the lily direct the fact that you know your insurance said your gp1 was this much money you know doesn't matter we can go get it for 500 bucks for lily direct i think the the presumption and i'm trying to to put myself in the shoes of of someone that isn't perhaps in this space like you The presumption is you pick it up from the pharmacy.

30:41It's the same place that you would pick up the Zep Bound or Wagovi. It's an American pharmacy and it's made by an American pharmacist. So it should be high quality. I wouldn't assume that things are just automatically high quality because they're made in the United States. We have multiple recalls of just food right now. just the manufacturing process and food safety standards or manufacturing safety standards, I wouldn't just, you know, assume that it is safe because they've actually have tested random samples from compounding pharmacies across the U.S. And just what's actually inside of them can be completely different.

31:20The purity or contaminants. Yeah. I've been running the proof now for more than eight years. and nobody warns you when you start a business that in the early days, this means you're also the HR department, the payroll team and the person reading the tax rules at 11 p.m. I can recall recently trying to get my head around employee benefits in California versus South Carolina. Enter Gusto. Gusto is an online payroll and benefits software that is purposely built for small businesses. It's all-in-one, remote-friendly, and incredibly easy to use. So you can pay, hire, onboard, and support your team from really anywhere.

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32:49I'm prescribing terzapatide. Well, actually. And what's the decision-making process there? Yeah. So let's start that over. So I'm prescribing what's on formulary. Break that down for me. I'm prescribing what your insurance company is going to cover. Okay. So what is going to be the most affordable option to the patient that day within the GLP-1 class out of terzapatide versus sumaglutide? Those are the two GLP-1s that are best for weight loss. Mostly on formulary is sumaglutide, Wagovi, because Novo Nordisk gave CVS Caremark or whoever, PBM, the better rebate. And so Lily got thrown off and they don't have terzepatide on formulary.

33:33So I'm mostly doing Wagovi sumaglutide if that's what the formulary like says. If I can, you know, terzepatide versus sumaglutide, I'm having better effective outcomes on every dose with terzepatide compared to sumaglutide. why wouldn't I go for trisepatide? If I'm having a patient that has a lot of GI nausea side effects on semaglutide with a GLP-1 single agonist, why don't I go try a double agonist GLP-1 GIP? It kind of depends. It's all about individualized medicine and what is accessible. And also what does that person have? Does the person also have sleep apnea? Then we should go for trisepatide.

34:12you know there's better evidence for that yeah well it's actually fda approved for that as well so i could go for that indication if they're not going to approve it for obesity i can go for sleep apnea are they the only indications is it is it sleep apnea no there's so many type 2 diabetes cardiovascular protection you can do it now for cardiovascular yeah yeah well they're gonna say having had history of a cardiovascular event and being high risk and so i've used to be able to go get a calcium coronary score and prove that they have coronary plaque. And I've gotten people approved with that, but now - Just on calcium alone?

34:52Having coronary, and then how they have hyperlipidemia as a complication, their BMI is 30. I've gotten that approved before, but now it's getting harder and harder. So now it's going to have to be like history of actual MI with obesity sometimes. And something about the Medicare bridge program that you know i just learned through practices that if you have sleep apnea you don't qualify at all it has to be isolated obesity which is so silly because that's such a common comorbidity have the the oral semaglutide drugs have they made this this class of medications more accessible yes with the when wagovia pill first came out with a snack snac um technology for making it persist beyond the stomach because it breaks down because of your stomach acid.

35:43That was really cool. But something about Wagovia pill is that there's a protocol to it. I don't like the word protocol. I don't know what it is, but there's a protocol to it. And it has to be on its own with four ounces of water. All of my patients are also on Synthroid or like Pentobrozole or something else. And it just became kind of cumbersome. And so I have loved prescribing, this is not sponsored, but I've loved prescribing Foundio because there's no protocol. You can take it with all your other medications. Yeah. I have mixed feelings about the word protocol too. Okay. What about it? I don't know.

36:20I just feel like now, like what's the thing? If you can't beat them, join them. I feel like... Is that me in longevity medicine? I feel like it's been popularized when people have a protocol, particularly if they feel like it's individualized. Perhaps it does help adherence. So I'm probably not as opposed to it as I previously was, as long as that protocol makes sense for that person. I don't need to use the word protocol. I'm a doctor. I can use the word treatment. Well, it really just, it's a prescription, right? Yeah, but you can't say the word prescription because you can't write it. That's right.

36:56So that you say protocol. Yeah. I write prescriptions. It sounds science-y and you can charge for it. Yeah, and you can charge, and you try to charge more money than I make. And you do. Congrats. You're smarter than me. I want to come back to the GLP-1 protocol and dosing and how you kind of titrate the dose and what happens if you need to come off and all that sort of stuff. But if we just, I just want to rewind a tiny bit. Okay. So patients sitting in front of you, you assess them and you understand that some of their health how they're presenting would be attributable to obesity how do you decide to have a conversation with them about their weight and do you have a conversation with every patient about their weight it's easy i ask for permission I'm doing your annual and I am thoroughly going through the same thing for every person, which includes your vitals and doing a physical exam.

38:00And I'm operating in a clinic in the real world in the United States where we don't have a body composition analysis machine. That is not a standard of practice across the U.S. People have got to understand that on the internet, but we are operating on BMI and it is unfortunate. Okay. So we can interpret BMI in a range. We shouldn't be interpreting it down to the number because I think the sensitivity of BMI to accurately diagnose obesity is less than 50%. So obviously why would we use that? But we're in an archaic system that needs updating. And until every clinic across the U.S. gets a body comp analysis this machine this is what we're doing okay anyway so i get the sense that that you have come out of your training into the real world and are perhaps a little bit frustrated well we're doing the best we can i think academic institutions and big hospitals and people that work there are doing the best they can and i think coming out into private practice and like the like the being on social media and like the wellness space and there's so much criticism towards the like the the traditional healthcare institution, which there should be.

39:09And there's a lot of internal criticism as well. But I think everyone needs to remember that everyone's doing the best they can with the resources they have. And so that has just been one of the biggest comments online is like, how could you be talking about BMI? How could you be talking about BMI? Because we're forced to operate with BMI. And the insurers are using it. The insurers are using BMI. I am forced to operate with it. I'm not saying that I should succumb to that and not get a body comp analysis on everyone. I do. I tell people I have found that resource in my community and I like help people get there to do it.

39:41But when I'm first doing an intake on someone and we're just trying to get insurance coverage for medical therapy, we're operating on BMI. And I'm saying it's terrible, but that is what it is. But even beyond, say, body comp, isn't the net outcome, so someone's HbA1c and blood glucose and their blood lippers, isn't that more important again? Yeah. No, it totally is. How is this translating into their physiology? Yeah, no, exactly. And that is another topic that I try to talk about online too. It's like, we're not criticizing the existence of a larger body. We're talking about becoming an obesity medicine doctor, in addition to being a family doctor, made me even less interested in weight alone.

40:28It made me even more interested with what that means for the rest of you as a whole person, what that means to like the quality of your life as you age and move forward. I get to see every single decade in my family medicine clinic. Well, that's such an honor to be able to do that. And I get to see how obesity and metabolic disease across 20s, 30s, 40s, 50s, 60s looks different for different people based on like access to medication, also the ability to make lifestyle changes. So that is what obesity medicine is. It's to improve your quality of life, improving your functional abilities, decreasing your burden of disease, what will help you age better, what will help you take care of yourself independently as you get older.

41:11You don't want to end up in the hospital. Also, if you get pneumonia at 80 years old, the person that has adequate muscle mass and healthier, just cardiometabolic health is going to be able to fight that off so much better than the 80 year old that has had metabolic disease their entire life. Also, it ties into so much more than that, you know, obesity, medicine and aging and like dementia prevention is a whole conversation, a whole topic. But. So you ask for consent. Yes. And then providing they're happy to have that conversation. I just ask for permission. I'm just like, hey, your blood pressure is great.

41:44Your vitals, blah, blah, blah, blah. I noticed that your BMI is above the, what we call the obesity range. is that something we can talk about today? That's something that has been, someone has talked to me about that before, but I don't really want to talk about it today. I'm like, okay. So you're going to need a mammogram and where do you usually get that? I just move on. So that's like the bedside manapace. Oh yeah. It's like you make it uninteresting. You make it part of just everything else that you're doing because it is part of everything else that you're doing. And I think there is just shame and stigma that is perpetuated with skirting around the topic.

42:22You know, just say it. Is that something I can talk about today? And then they don't want to talk about it. I'm like, okay, we're going to move on. Is that a common approach you would say among your colleagues? I think like Gen Z and young millennial doctors, like we're more chill about it. So what are the older... Everybody needs to be more chill. What are the older physicians saying? Everybody needs to chill out. Do you know what the older physicians are saying? How are they approaching that? I guess they might say that they're also not tiptoeing around it. I guess. Or being clumsy about it, maybe.

42:59Or jumping, like, why did you only hone in on the weight? You know, the blood pressure was also high. You didn't spend as much time on that. So it's just a little bit less sensitive. Like, I don't know how to explain being nice. Just be nice, you know, and try not to humiliate people and try not to make them feel bad. and you already know you're going into a topic that is pretty difficult for most. And so be extra nice. So once you realize that someone is happy having that conversation, what does the decision-making process look like? If you have someone in front of you, when do you decide, actually, we should just focus on lifestyle first with this person, whether it's nutrition and diet and then maybe later on look at a GLP-1 versus we should start a GLP one.

43:48Yeah, so I just asked for permission. Hey, can I talk to you about your BMI? And then most people go, oh yes, please talk to me about that. You know, most people just kind of like collapse and go, oh my God, it's been, it bothers me. Like it's something that I've been struggling with for so long and it's actually something that I wanted to bring up and talk to you today about. And then you just go, great. So that's perfect. I'm a family doctor, but I'm also board certified in obesity med. I would love to talk to you about that. And then we do. And it starts with taking history. And then I start by just sitting back and I ask open-ed questions and I start, how long has your relationship with weight been an issue for you?

44:27How long have you felt that tension with your weight? What's that relationship like? Did that start when you were a child, when you were a kid? Did that start after you had your first child and you were pregnant? Is it happening now for the first time ever? We're in perimenopause. Is it because of a medication that you're taking to stabilize another medical condition? Are you finally stable on your antipsychotics, but it led you to increase your appetite and now we're blaming you for being lazy, but it was like medically induced. That's not fair. There are common medications that increase appetite.

45:03Yeah, quite a few. I would say that there's now a beautiful overlap with psychiatry and obesity because we finally have the ability to stabilize people with their psychiatric medications, a lot of antidepressants drive appetite. A lot of antipsychotics drive appetite. A lot of rheumatology and obesity medicine also has a beautiful overlap because a lot of autoimmune disease requires up until more or better medications come out, but a lot of steroids, a lot of glucocorticoids, and that causes water retention and that drives glucose up and that drives insulin and it can drive blood pressure. And, you know, someone's lupus is well-controlled on steroids, but now she has metabolic disease and she has central adiposity.

45:53We can treat both now. So it's like this new dawn. I got to go through training of a new dawn. It's so cool. Can you imagine being a doctor 10 or 15 years ago and not having access to GLP once? Oh, sorry, guys. That's terrible. That's like when I started training and people were like, oh, this is like when statins came out. I'm like, what? Statins came out in the late 80s, 90s? I don't know. Someone was like, this is like GLP-1's coming out. This is like when the statins came out. I'm like, you were alive when the statins came out? When did the statins come out? I've had a few cardiologists on the show and they've spoken about life before statins and how scary it was.

46:31Oh, I know. I was making a joke. No, of course. Yeah. so patient uh in front of you you ask all those questions about like how long they've been kind of dealing with body weight issues and you decide that this is best for this person to start with lifestyle what what does that kind of advice or recommendation usually look like i don't think that there's a hierarchy to your treatment plan. It all can happen all at once. It just depends on the individual person and what they're ready for. So if someone wants to create a lifting plan with me, first of all, I'm not a personal trainer. Please, if you have the ability to go get a strength coach or a personal trainer, would love that.

47:21But if you don't, I would love to talk to you about it with the time that we have. So they leave with like... How much time do you get? Oh, this is so sad because I'm in the insurance model right now. It's going to change, hopefully, but it's follow-ups are 15 minutes. Initials are 30, which is unheard of, too. I get 30, which is great, 30 minutes. And then follow-ups are 15. But I've, you know, I've tried to sometimes double book some slots because there's a certain people you're just like, oh, no, they need more time. Plant favorites. Well, they're needy. they're just like they need more so you just make more time for them but it's about individualized care which is why when there's a fee-for-service model a dpc model you can spend apparently not that i know but like you know endless time with people because you don't have to see 20 a day to keep the doors open so they leave with you were saying so they could leave with a workout plan and motivational interviewing surrounding that and a prescription for glp1 i don't need to do the workout plan first and then you get to deserve medication later i find that to be just we don't do that for anything else someone doesn't have to have tried to let's say change their diet and then i've been unsuccessful before being indicated for a glp one like with an insurance company i don't know the answer no no some insurance companies it's ridiculous will be like you'll have to have tried a stimulant first for six months, like fentramine, yeah, fentramine before you qualify for a GLP-1.

48:56That sounds uncomfortable. Yeah, it is uncomfortable. And these people have had a pressure sometimes. I would hate that. That would give me crazy anxiety. It's crazy. No, it does give people crazy anxiety. So out of, when you're practicing medicine, what's the right thing to do? It's not to create a sense of, you know, you deserve this. We don't do that for anything else. We don't say, I'm not going to prescribe you an SSRI for your depression until you go to therapy. We're not doing that. That's the same thing. I'm not going to, you know, I'm not going to prescribe you a GLP-1 until you go see a registered dietitian.

49:24That's ridiculous. I love registered dietitians. I love strength coaches and they're all part of the care team, right? The physician is one part of the care team. Your registered dietitian is another valuable member of the care team. Strength coach, your behavioral therapist, your like mental health provider is another one. And if I could have enough time to set everyone up with like a referral to every single one of those elements all on the same visit, including, you know, medication and have enough time to give all of that justice, all of that can happen at the same time. But, you know, people will be like, well, you should have people prove that they can preserve their muscle, that they're going to go work out, that they're going to lift.

50:02And, you know, because isn't that the fear that people are going to lose their muscle mass? I have people that find it so motivating to be able to get control of their food noise, that they actually have lost a little bit of weight, and that is so motivating to them that they are now going to the gym for the first time ever. Like being on a medication to help them get control of their thoughts, these pecking thoughts, this cognitive burden of thinking of food and eating all day, just being able to silence that for the first time in their life and having the mental capacity to go and put that strength towards I'm going to get myself to the freaking gym today.

50:43I see that all the time. Is that how you explain the way that GLP-1 medications work to your patients? I love talking about that. I love saying treating obesity is treating the brain. I love saying that. Of course, it does way more than just acting on receptors in your brain, right? But that's a game changer in terms of how we think about this because in decades gone by, it's incorrectly being positioned as a lack of discipline or willpower. Yeah. But behavior is within biology, right? Biology and genetics and epigenetics and your society, larger society around you shapes behavior. So you're saying discipline, willpower is downstream of food noise.

51:24Yeah. Like in that, there's a relationship there. Oh my God, completely. The more food noise you have, less quote unquote discipline or the harder discipline it's going to be. Oh my God, are you kidding? Which means it's not an even playing field. No, it's not even playing field at all. Yeah. And people are shaking their finger and telling people to eat less and move more. You have never been inside that person's brain. You have never walked their shoes. You have no idea the brain they have and what the hunger that is driving in their brain. Do you get reports from your patients that start a GLP one and they come back I can say, hey, I feel less desire to drink alcohol or other behaviors.

52:06All the time. I'm off label with addiction all the time. I love it so much. I'm proudly off label with GLP-1s and addiction. We can talk about it. Let's do it now. Yeah. So I have seen just like anecdotally. I love saying anecdotally because now no one has to be like, well, there's no evidence. anecdotally in clinic everyone doesn't want to drink alcohol anymore like everyone it's crazy everyone on a GLP-1 everyone on a GLP-1 sorry that was in parentheses yeah everyone on a GLP-1 doesn't want to drink as much alcohol anymore it is all about the the mesolympic system the reward system it is all about that do they want to have sex yeah they do I haven't I've seen so much content about that.

52:50I'm like asking all my patients, I'm asking, I'm like, how's your libido? How's your libido? What's going on? And they're like, fine. But I'm also like, I also I'm treating a lot of perimenopause and putting people on testosterone a lot. So, you know, confounding. Anhedonia part, I'm seeing that. We can be honest about that. I'm seeing anhedonia at higher doses, lacklusterness, kind of like lack of wanting to do things. Like a dullness. Yeah, like a dullness to things. Like I don't want to get off the couch and go do what I usually love to do. That seems important to monitor. That is so important to monitor and that's why you need to go see a doctor and be surveilled by a doctor.

53:26You're not allowed to let that. That's not casual. And hedonia is not casual. You need to... Have you seen that clavicular kid on the internet? Yes, unfortunately. I love that you said his name wrong though. Crazy. Is it clavicular? Something like that. Yeah. Why does he think that that's a cool name? I don't know. But he put up a video that someone sent me saying he was taking 10 milligrams of retta 2 tried. Oh, God. Which you can't even access, so I don't know how he's getting that, but probably from a compounding pharmacy, I guess. All compounded retta is illegal. Like, people don't know that.

53:56It's illegal, right? All of it's illegal. At the moment, because it's only, has it gone through phase three yet? No. No. It's not done. It's all compounded retta is illegal. People don't know that. I don't know why people don't know that. And he took 10 milligrams and was saying it completely crushed his libido and just all motivation. Yeah. I mean, I'm sure it just like did a lot of other harm too. So in clinic, you're monitoring that? Yeah. And that affects the dose that you might prescribe? I see it come down when you decrease the dose, if you decrease the dose. How do you start a dose with, I mean, you said you're mostly prescribing trisepatide.

54:37So if we just work on that. Either one, semaglutide or trisepatide, you start from the bottom dosing. Bottom dosing. Yeah. Which is? the 2.5 or the the 2.5 milligram for chersopatide which goes to 5 which goes to 7.5 which goes to 10 12 and a half 15 and i and i try to go you know systematically i don't jump doses people will be like i don't want to i this one felt like the last one i'm like okay well it's still doing all these other things for us right it's like lowering your heart inflammation and it's treating your insulin resistance and um like we're still at least maintaining and then we go up and dose appropriately the next month.

55:11It never wants to feel like a runaway train with how like, like crashing your appetite down to nothing. Right. That's something that I'm constantly battling is, are you eating enough in clinic? Given that some of these people or presumably most of them have dealt with this food noise their entire life, that would be tricky because they may not understand what a normal appetite is. I know. And then they come back after being on the medication and they're in tears sometimes. Like people will legitimately come back and be like, I didn't think about food. Like constantly the whole time, like the second after I injected, it's not going to be like the second after a little placebo, but.

55:54And how would someone know that their dose is too high? Is it they're just losing too much weight too quickly? There's a lot of factors. It's guided like by side effects. So if someone's having a terrible nausea or acid reflux or constipation, we're not going to increase your dose today. Like we are not, if everything isn't well controlled already. If someone is, like rate of loss is too fast, you know, then we are worried about muscle mass loss. And if you're going to lose weight fast, then most of the time people regain weight fast. The slower you lose weight, the more sustainable it is. There is a set point theory to our hunger in our brain.

56:30And it's if we are lowering our hunger more slower, are we also altering the set point to our hunger? You know, when we take off the GLP-1s, it's not that you withdraw from the medication, it's that your biology, your brain comes flooding back to what it was and people do regain weight. And is that set point changed after it's been on a GLP-1 for so long? Or is the set point go back to what it was from before you were ever even on a GLP-1. That's a big question mark. But what I'm seeing is that people's hunger comes flooding back. And because they haven't had that input for a while, subjectively, that hunger feels very strong.

57:18This is when they come off of it. When they come off. They will tell me my hunger feels even stronger than before I was on the GLP-1. and I don't think it's necessarily true that your biology or chemistry has changed. It's just that that input signal you haven't felt for a while now feels subjectively stronger to you because it's been gone for so long. It's been suppressed on the GLP-1 and now you're feeling it and it feels so strong. Something to contrast it with. Yeah. When that muted signal, so it makes it more obvious. Yeah. I think Kevin Hall might be the one that will study that. the the set point i know that he's he's i mean he's been interested in that his whole career and now he's doing research on glp1 medications yeah that's so interesting when you're explaining to a patient uh how glp1s work i'm sure they ask you am i on this for life how are these these medicines, quote unquote, design, like if someone is tolerating them well, in the perfect world, what does it look like?

58:25So someone will ask me, do I need to be on a dual-team for forever all the time? Like it happens multiple times a day. And the first thing I do is I pivot it back and I say, so it's not about thinking about forever. It's about thinking, if we take it away, what do we know happens, right? Because that's what we operate on. We operate on evidence. Who's saying that they should be on this medication for forever? Well, no one's saying they should be on it for forever. We have evidence to show what happens when we come off. That's what's important. When we study people coming off of GLP-1s, the A1C goes back up.

59:05The high blood pressure goes back up. The central adiposity, waist circumference goes back up. We know that's directly tied to cardiovascular risk and outcomes. So it's more about, I have evidence to show us that if you stay on this medication for a long time, as long as you're on it, these parameters can be controlled. And in the studies that we have, a certain percentage, the vast majority, like it's mostly around 60 % of the people they studied, their parameters or their cardiomyopathy parameters worsened again. Now, I've had really cool conversations with patients in clinic where they say, well, what about that like 17 % or 15 % of people that didn't regain their weight?

59:52Those people are part of the study. Yes, they are. My patients are so smart. Thank you for bringing up that population. That might be one of those. Yeah. Are you one of those? I don't know, but that would be so cool. What if you are? That's so cool. Maybe you are. I'll help you. You want to get off? Let's try it. I will tell you that your brain chemistry is going to come flooding back and I'll be here for you if you ever want to go back on. That's the conversation. And if someone loses the, let's say, the target amount of body weight, maybe we can talk about how you create a target, what that looks like.

1:00:26Everyone wants a target. It doesn't exist. Do they tend to? The limit doesn't exist. So when do you know that that's enough weight loss for this person? Yeah. They're at a healthy body weight. Yeah. That's the first part of my question. And at that point, do you tend to just maintain the dose at wherever they were at at that point, or are you lowering it? Yeah. So my practice has evolved over this past year. I'm out solo practice, attending life, you know, out of training, doing it on your own. And so instead of lowering the dose when they get to target weight, and we can talk about how you decide on that, I am trying to land the plane more gently before I even get there.

1:01:09And so if I see us approaching based on, okay, so look at the curve of loss, look at the data. And if it's creating a C curve and they're curving out and we're approaching their target weight, we could start taking down their medication a notch now because depending on the rate of loss and the curve of that data, I'm like, you're going to continue to lose weight. But you said there is no target weight. So what is the target? The target weight is the target weight that I individually decided with my patient based on all of the factors that are specific onto them. And the target weight is likely never down to a singular pound specific.

1:01:48It's probably, we're going to say like 140, 145, like around there, operating in ranges. because going down to the singular pound is a little bit silly because total mass loss doesn't tell us anything about body composition or reconstitution. So you're looking at that number, but presumably, again, you're coming back to like, what's their blood pressure doing? Exactly. Like what's actually going on with your health? What's actually important, right? And it's about understanding and having so much fun explaining, you mostly lost visceral fat. You know, you're looking in the mirror and you're still telling me you're not really noticing the weight loss or the subcutaneous fat still really bothering you.

1:02:30You know, people are like, oh, my arms. I'm like, but the weight loss that, you know, 10 pounds that you lost in the last three months since I saw you, that's also clinically significant. Look at your blood pressure. It came down. Just 10 pounds. Where did you lose it? You lost it in between your organs. The really damaging. They're really damaging. The infiltrating fat. And then we run labs six months later and their liver enzymes are down. And it's like you're celebrating those small wins, the actual important and the whole picture, not one singular number ever. Yeah. So like you can't hone in on just getting like the homeostatic assessment for insulin, the HOMA-IR, and saying like this person now has insulin resistance.

1:03:11What? No, no, no. It's not standardized to that. It hasn't been evaluated for that. It's not what it's measuring. You take that into consideration with them having hyperlipidemia or having high triglycerides. You take it all into consideration, but these are all good tools to evaluate someone with obesity. I know that with these drugs, you'll see improvements typically in insulin sensitivity and metabolic health. Are you also seeing changes to blood lipids like someone's LDL cholesterol level, ApoB? Do they tend to improve as well? Completely. You know, patients are oftentimes like, oh, does this mean that I don't need a statin now?

1:03:46That's not what that means. Yes, your cholesterol improved. But, you know, I am so thankful they just came out with new dyslipidemia guidelines for 2026, which is great because they hadn't done that since 2018. And so they have like LDL cutoffs. Everyone should be under 100. And if you have elevated LPA, consider getting LDL under 70 and total should be under 200. And now we have guidelines for, you know, starting at 30 years old, which only speaks to the metabolic crisis in the U.S. Like we have official medical society guidelines starting at 30 years old for dyslipidemia in the United States.

1:04:22That, just saying those words is a little alarming. And 30 is young. I'm 30. You know, I need to go get my cholesterol checked. Speaking of, I should probably go do that. You should. Because you are young and you look very young that people underestimate your experience. And I mean, it sounds like you're nerding out on the guidelines and you really get into the weeds and you take a lot of care with the way that you practice. But I imagine some people, their experience of you online or even seeing you as a physician might be, well, she's extremely young. I get it all the time. How old are you? Yeah.

1:05:01all the time. And at first when you are young, like when I was going through training and I'm 26, 27 and you walk into the room or you're presenting on rounds or whatever it is, and people don't want to take you seriously, it does hurt your feelings because you really want to try and like do a good job. Now I'm 30 and I don't really care anymore. You know, I actually think it's kind of, now you're just like, well, I actually went through medical training and residency and I survived that. So if you don't want to take me seriously, like someone like random on the internet, it's almost like laughable because you just lean, you know, and I'm talking to my young docs out there who are trying to create content online, like lean back on your training.

1:05:38No, you went through medical school. You took all those boards. You went through medical residency. That's more than the person who was about to be the Surgeon General of the United States did. She didn't finish residency. I finished residency. Is that still happening? I think that - No, she's out. God, thank God. No, she's out. Thank God. Historical now. No, like literally what? What are we doing? Anyway, so I was, you know, I was more qualified than the person up for Surgeon General of the United States. Okay, cool. That's awesome. All right, gents, listen up. If you are trying for a baby right now, Swim Club is worth knowing about.

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1:09:09It means that I finished intern year and then I did finish residency, which is after intern year. And then I, in family medicine, and then I passed my board exam in family medicine. And then I sat, And then I did the CME pathway for obesity medicine, which was accomplished by doing an obesity medicine, like track within family medicine in my training. And then I took the obesity medicine board exam as well. And then on top of that, you just mentioned the 2026 dyslipidemia guidelines. So it's part of your job. That's the American Heart Association. It's just to like stay up to date on what are the societies saying?

1:09:40But is it part of your job to stay on top of all of those? It should be. It should be part of our job. If you want to be evidence-based, you've got to know what the medical societies are saying. if there's a new like massive trial that just dropped like a head-to-head trial for like the two biggest GLP ones everyone's talking about and you're an obesity medicine doctor you should probably know about it is every physician doing that well I don't know I don't know I don't know no I don't think so I don't know what do you want me to say what do you want me to say I don't know I think I think there's a lot of burnout I think it's really hard for people in traditional insurance practices to have time to, you know, really dedicate themselves to the art and craft of medicine.

1:10:21I can see it because I'm in it now. It's like you see 20 people a day and then you have an inbox after you're done. And then you're also supposed to be like reading up on the newest guidelines. And then you're also supposed to be making content online. And then you're also supposed to be a good family member to your, and have friends and, you know. It's a lot. It's a lot. How can a patient then quickly, I guess, determine if their physician is staying up to date and is giving them evidence-based recommendations? Like what are the green flags or red flags or questions to ask? The questions to ask are, I'm here to see if I have obesity and to be evaluated for that.

1:11:00And if I do, why do you think I do? And if I don't, why do I not? and what are my treatment options for having this condition if I do? And if I don't qualify for a GLP-1, why wouldn't I qualify? Just like having open dialogue, I would hope most people can have that with their doctor. And you mentioned the GI side effects. Uh-huh. They're probably the most common side effects that someone might experience acutely. It comes from the mechanism, which is the delayed gastric emptying. And people who have obesity sometimes already have gastric esophageal reflux disease. They already have that. So it's just worsening momentarily.

1:11:37But treating overall obesity would improve GERD overall. So do you explain to them ahead of time that they may experience this or does that just increase their chances of experiencing it and you more wait for them to present? No, I tell them every time. No, that would be terrible. Oh my gosh. No, I would rather... Well, I ask that because with statins, I know that the discussion around the side effects of statins, there's a strong nocebo effect. Yeah, yeah, yeah. Which is real. The patient still experiences those symptoms. Yeah, the myopathies. But the kind of stigma associated with statins definitely affects the experience.

1:12:12I would say that the side effects from the GLP-1s are much more common and strong than the side effects from statins. Like having nausea and acid reflux and constipation from a GLP-1 is very common. And how do you help the patients kind of reduce the likelihood of experiencing those or at least make them not as severe? Fiber, fiber, fiber, fiber, hydration, hydration, hydration. We talk about nutrition. I think that it goes into public education in the U.S. is knowing basic nutrition science. What is a macro? Protein, fiber, fat. We're starting there, truly. and people feeling confident and identifying what their food is and how it fuels their body.

1:12:53Like this breaks down into glucose and can only do this, you know. But for constipation, it's all about fiber. And for women, usually 25 grams a day. And for men, I usually recommend around 30 grams a day. And evenly distributing protein and fiber throughout the day as well because people will be on a GLP-1, not feel hungry, and then they'll just crash at the end of the day. And they'll try to eat all of their protein, all of their fiber just at the end of the day. And that's not the best way to do it. Do you find that that is challenging when they have a lessened appetite to get enough fiber from their diet and protein through the day?

1:13:27Oh, yeah. Like people having a hard time reaching their minimums. Yeah, that usually means the dose is too high because you're not supposed to not be eating, right? And that's why I really hone in on the details with my patients when they come in. I go through hopefully the same checklist with everyone. But are you actually meeting your protein goals? are you meeting your fiber goals? I am not a registered dietitian. They are also getting a referral to a registered dietitian who has way more time and expertise and we'll talk about that way more. But I do cover just the basics along with talking about medication prescription in a clinic.

1:14:01So I'm setting protein minimums for people. I'm setting exercise goal minimums for people. And a goal is a goal. I tell people, try your best. You know, people come back and they're like, I didn't do what you said all the time. And it just kind of is like that. But that's what built the relationships. You want them to come back. Is the hydration difficult? Is it similar to food in that people would have less urge to drink water? Yeah, I have seen that for sure. People are not thinking to drink as much water. The hydration goes down. That sounds like an important thing to be aware of. It's extremely, it's very important.

1:14:34What are the consequences of not staying adequately hydrated while you're on a GLP-1? Oh, it's compounded by the side effect of constipation as well. And so you're not thinking of drinking as much water and you're constipated. So it's worsening. One's worsening the other too. And so lightheaded, dizzy. Yeah, no, people are just feeling tired and fatigued for sure. Is the best way for someone to know if they're drinking enough water to look at like the color of their pee? I think so. Yeah. I don't know. Is this something that patients ask? I recommend like a total daily fluid, like around 1.5 liters of water and also like hydration.

1:15:13Like your pee. Unless you're ever taking a multivitamin and then it's going to be fried. Yeah. Like all of a sudden you're on like B vitamins. Like people are going to be like, well, what if you eat a lot of like carrots or you take a B vitamin or whatever? There's like, like what's a board question where it's like the pee was freaking blue or whatever. Sure. That happens. Yeah. I don't remember what it was though. Yeah. Yeah, I know that peptides are hot and all the rage right now and everyone's talking about them. And I think GLP-1s have kind of helped bring peptides to the general public. Yeah.

1:15:47But I think it's too premature to lump all of these other peptides in the same basket. Totally. And people say peptides like it's all like, ooh, peptides. Peptides, like insulin's a peptide. Everyone loves to forget that. I'm worried about a lot of these peptides that are jacking people particles growth hormone IGF-1. Yeah. For the wrong person, I think that could be pretty problematic. Oh yeah, totally. And it drives angiogenesis. Okay. That's a, that sounds like - Which could be good, but it could also be bad. No, exactly. That's an element to a neoplasm is that it has its own ability to create its own blood supply and create its own blood vessels.

1:16:24And we're injecting, and we need to talk about bioavailability and risk profiles. I think we can get to 80 in pretty good health and spend most of our life being able to do the things we want to do, touch wood, without having to do anything too crazy. Oh, yeah. Like the basics of health? Yeah. And yes, we have differences in our genes and food noise and biology. And you can layer some evidence-based pharmaceuticals on top of that. And that's a great approach. and it doesn't need to be super extreme where we're experimenting with compounds that we just don't understand efficacy and safety. Yeah, and that's gonna what, make a 5 % difference to your overall health, if at most.

1:17:05It's what I'm trying to say is such a small difference. If you're not sleeping well and you're not lifting and you're not eating well and you're not doing all the other basics and like all that other stuff doesn't matter. I think it's a shame now to see longevity medicine almost. it's becoming biohacking and becoming a little bit extreme when the message that I want people to understand is that those practices are not really longevity medicine. Exactly. And that's why I have initially rejected the word longevity medicine, right? Because that's all that I saw it represented as was a market that was created because of a void with people just looking for health care and spending all their money on opportunistic kind of longevity companies or influencers or like or operating on fear mongering when none of those things are actually like the basics of health at all basics of health are found in a family medicine clinic with someone telling you and guiding your health and having a longitudinal relationship with your family doctor that's actually like the basics of health and that's real longevity medicine is funding a robust family medicine, like infrastructure and system.

1:18:19And changing back to our health, our environment, restructuring the environment and access to healthy food. Exactly. These kind of big levers. But even if you're someone that has access and you're in a higher socioeconomic class, you're not going to biohack your way to being 100. I think people are putting far too much time and energy into those sorts of practices and overlooking that what matters most is these basic pillars of health and not whether you can do them perfect for a week but can you do them kind of imperfectly but consistently over your life what's sustainable and that's what I'm trying to do in clinic is motivate people to have a relationship with working out that's one of the biggest things that I found is like beyond just prescribing medication, what am I spending a lot of time with people is the relationship they have with food, the relationship they have with working out.

1:19:12I need them to either begin or create some kind of plan that is sustainable for the rest of their life. And in a relationship, you give and take. So you give and you get back. So you got to put in discipline and put in hard work and your health will improve and you will feel better and have more energy and you'll have more muscle mass. That's what I'm trying to motivate people. And I think it's a lot of people have a hard time in the beginning, but eventually if they come back, that continuity, that trusting relationship that you can build with a doctor, the one like where I'm always checking in, in a empathetic way, it actually does motivate people and people do end up taking that first step of I'm lifting weights once a week consistently.

1:19:56And I have been doing that for eight weeks consistently since the last time I saw you. That person had seen me for six months and then decided to start making that change. Because every time I saw her, I was like, you can do it. And next time I saw her, she hadn't done it. Something else had come up, yada, yada. She's like high functioning CEO level, like winner at life at everything else. There's always something else, you know what I mean? And then finally she decided if I don't create time, if I don't make time, it's not going to happen. And that came with sacrifices, right? And so we have to like let people get to that place naturally too.

1:20:32Your role as a family doctor and as obesity medicine doctor is to guide your patients and help them make the best decisions for themselves, not dictate their decisions. People will make their own decisions. You're supposed to present the best information to them. Also to help them prioritize. So like orienting someone towards resistance training as a good use of time is going to be much more powerful than orienting someone towards methylene blue. No, right. Exactly. Like someone talking about methylene blue on the internet doesn't see actual patients. Like, get out of here. That's what I get to do.

1:21:01I get to make direct eye contact and stand in front of my patient in clinic. And I know like she's a busy mom and she's only going to have an hour this whole week to herself. And she is going to pick weights. And I'm like, I look at her and I'm like, I know you want to pick the run that you always go on. But this week, we're going to do something different. We're going to lift weights with the time that we have. Like I'm having that conversation constantly. I don't think you should reject the longevity medicine phrase description. I think you should just take it back, Reclaimer. I'm taking it back right now.

1:21:35It's official. It's actually like longevity. Family medicine is longevity medicine. Actually, all y 'all are trying to practice family medicine and you're doing it wrong. I like Debra Cato. I don't know if you know her. She came on the show. She's a gerontologist. Oh, cool. And so I think gerontologists of all doctors are the most frustrated with longevity medicine. Ah, yeah. Yeah, yeah, yeah. Totally. I could totally see that. Because they're actually the physicians treating elderly. And her description, which I now use for Healthspan, is not the number of years that you live disease-free. It's the number of years you live with a high quality of life, independent of whether you have a diagnosis of some type of disease, like diabetes or obesity, the number of years you're living where you have a high quality of life and be able to do the things you want to do.

1:22:26Exactly. I talk about that all the time. And it's like not about aesthetics. It's about like your health span and your lifespan. And that is longevity. And I guess in a way I could say that I practice longevity medicine, but I'm proud to say that I practice family medicine. And family medicine is the original whole person specialty, actually. Wait until you see the title of this episode. I might try and put longevity in there. You can. I would love that. But it's that family medicine is the original longevity medicine. What does family medicine actually mean? taking care of people from womb to the day that they die having the skill set to practice primary and preventive care for a newborn baby as well as children and every single member of the family and also how with a focus on how a family fits in to the context of within themselves as a family interpersonal intra relationships and then their larger community which is also why i'm like very like naturally socially oriented as well is because family medicine is like, how does my patient exist in the wider context of the real world?

1:23:33And how, you know, how do we actually deliver care practically, tangibly? You know, we can talk about it online, like what's the best thing, but how do I actually get this to happen for this person? That's actually practicing medicine. That's like navigating the barricades of real life. We've kind of touched on funding, insurance. What are the biggest barriers that you're facing? The biggest barriers or the biggest threat to American healthcare is the health conglomerates. It's the health insurance conglomerate companies. It's the giant United Health Group. It's the giant CVS Group. It's the giant Express Groups.

1:24:10It's the pharmacy benefit managers. So I could start from the top. It's like I had to, and by the way, nobody tells you about the system that you enter to work in along the way. Nobody. Don't tell me that because I was very in tune and aware with my training, very hands-on, very motivated, invested. If there was a, like, how to, like, actually come out of training and exist in the real world course, I would have taken it. Like, we don't get trained. You just enter, and then all of a sudden, first day on the job, you've got, like, 10 appeals waiting for you and 10 letters waiting for the 10 patients you saw this morning.

1:24:45But that's what you're going to do after the job is done. You're going to go home and do it later. Did I say that you went a year without getting paid or something? Yeah. Blue Cross Blue Shield, my member ID number is wrong and that is an administrative end on their end. And they're not paying me for, they have, they're just saying that there was something administratively wrong and they're not going to pay me for the whole year. So, so far right now, we're trying to get retroactive reimbursement. We, as in my medical practice admin, are trying to get retroactive reimbursement from Blue Cross Blue Shield, but that's currently happening.

1:25:12Yeah. So how does that affect me? Like that affects my production bonus because you have a base salary as a physician. And then when you're in private practice, it's very different than being in a hospital practice. Hospital is RVU based. When it comes to private practice, it's all based on production. What did you charge the insurance company? What is the reimbursement that you got? So do you get paid based on the number of prescriptions? No, I do not get paid based on number of prescriptions. There's, um, there's, it's the level of, it's the time spent with patients that you, like you can bill for.

1:25:40Is there any loopholes or channels that you're aware of where people can access prescription medications more affordably? Yes. And this is something that I love to talk about. And it's how do we increase access? We circumvent the pharmacy benefit managers completely. What's a pharmacy benefit manager? It is a company that exists in the vertical chain, like in the manufacturing process. So basically, the manufacturer creates the drug and sets a list price. And behind the scenes, before the patient actually walks up to the pharmacy and gets the medication, the pharmacy benefit manager has negotiated with the manufacturer and the insurance company where on the formulary list, this medication gets placed.

1:26:35for preferred placement. And they do that by taking rebates from the manufacturers. And so it's basically multiple versions of a price that get passed back and forth and decided between the pharmacy benefit manager, which is just a company that basically like organizes this process between everyone and also increases, can increase the price in between the manufacturer and the actual patient picking up the pharmacy. But you can cut them out. You can cut them out. But we haven't done that except for one. One company does that. And it's Cost Plus Drugs Pharmacy by Mark Cuban. There's one pharmacy right now.

1:27:13Is that a plug? Yeah, go do it. Go use that. But is this like a paid plug? Oh, no, it's not. I wish. Okay. That'd be freaking cool. I just want to clarify. Hey, Mr. Cuban, I would love that. If you ever hear this. We love Cost Plus Drugs. Wait, so Mark Cuban, he has made that possible. So he started Cost Plus Drugs. Not just him. It was a couple of people. and they don't deal with pharmacy benefit managers at all. That's like one of their philosophies. They buy directly from the manufacturer. They have a universal increase in price to be able to cover their operating costs. And then they sell it to you at a transparent price and they tell you exactly the markup and why.

1:27:51So you're going there if your insurance is not covering you. That's an out of pocket avenue. Yeah, yeah, yeah, totally. Same thing with GoodRx. GoodRx sources all of the best prices at all the pharmacies. They're not reinventing any prices. They're just finding the best deals. And then you use that coupon at the pharmacy. So that's what GoodRx is. I used GoodRx. I take Repatha, a PCSK9 inhibitor. So you have to use the GoodRx coupon for that? I use GoodRx. And at CVS, it was like, the last time I picked it up was like$35. Nice. Instead of like, it's usually thousands of dollars a year. Thank you, GoodRx.

1:28:30And TrumpRx is the same thing. It's a coupon website. And so what are they doing? They're sourcing all of the best deals that the pharmacy benefit managers have set, but they're not eliminating the problem. That's my one criticism to GoToRx and TrumpRx. It's not revolutionary. They're making it easier for you. They're finding you the best prices, but they're not doing anything to change the system. Cost Plus Drug is actually just not negotiating with the pharmacy benefit managers at all. So if we sit with this for a moment, because I grapple with this, The pharmaceutical, often the pharmaceutical companies are kind of painted out to be overly focused on profits before health, etc.

1:29:14But really, they're the ones that are investing into the clinical trials, into the drug development, and they spend a lot of money. Yeah. They deserve to make a profit. Exactly. They deserve to make a profit. And the American public, or whichever country, deserves access. Right. So in an ideal world, both is occurring. Exactly. And like that all comes down to how do we even set price, drug prices in the U.S. Like we don't have a single payer system. So I'm originally from Sweden and like we're a single payer, like the country, the government is negotiating on behalf of the people. And so there's one set price on behalf of like everyone in Sweden is going to go spend the same amount of money.

1:29:53I'm talking to my cousins in Sweden. I'm telling them everybody's spending the different kinds of money on their drugs because they all have different business plans with their insurance companies. if they find it to be so predatory. And I agree with them. But basically, like, the government has negotiated the price of the drug on behalf with the manufacturer, like, let's say, Novo Nordisk. And that's what the price is in Sweden. Whereas, like, you know, before the direct-to-consumer price, this is what the price is. It's lots of different things, like, just depending on what your insurance plan is.

1:30:20It's crazy. A multi-payer system is so confusing. And they don't teach you any of this when you go through medical training. They don't teach you any of it. So you're very green when you come out. Very green. and you have to keep asking yourself why, why, why. You keep like learning, learning. Just keep asking why. Why does this person not get their medication? Why does it cost this? Who made that decision? What? Just keep asking why. You mentioned babies. Have you heard of Ozempic babies? Yeah. We're lowering people's inflammation by decreasing their, most likely their visceral adiposity. And for women, you know, about one in 10 women of reproductive age have PMOS.

1:30:57So that's a lot of people. And so, you know, these people are not used to being fertile. They have had actual infertility issues, you know. So birth control isn't potentially at top of mind. And so when we're treating their cardiometabolic disease from obesity to, let's say, diabetes, they're all of a sudden starting their menstrual cycle and getting pregnant. So it's a good thing, osmbic babies. Well, you— Is there any concern there that a baby would develop inside a woman who's on a GLP-1? Are they meant to stop when they find out they're pregnant? Or what do we understand? We don't have the data.

1:31:38That's where we're at. We don't have the safety data surrounding GLP-1s and pregnancy. We also don't have it for breastfeeding. That's why we're saying, why would we take the risk when we don't have the information? Have I seen anything anecdotally about it being dangerous? No, not at all. GLP-1s don't cause necessarily like hypoglycemia in mothers that then causes hypoglycemia in babies. We haven't seen things like that either. If anything, we have seen GLP-1s being used to treat metabolic disease, which actually allows for healthier pregnancies. I guess a similar potential risk is there with regards to adequate nutrition that we were speaking about before.

1:32:18Totally. Exactly. Adequate nutrition at all is important in pregnancy. And so then if you're limiting someone's nutritional intake, especially someone who maybe doesn't have all the resources to make sure that I hit my protein macros, all those things, that could be a risk. Because it's quite a depleting phase of life for a woman, right? Pregnancy. Oh, yeah. Well, also... I say that from a nutrient status point of view. Yeah. What do you mean? It's depleting. Like iron stores go down. Oh, yeah. and there's higher requirements for certain nutrients. Oh, yes, totally. And a GLP-1 being like complicating that her prenatal course.

1:32:56Yeah, making that even harder potentially. Potentially, absolutely. But I think that you would have to be very sensitive in fine-tuning with someone given how much reserve they have. So like, what is that person's body composition? You know, how much is it medically appropriate for someone who is pregnant to be on a GLP-1, let's say if we do have the safety data eventually, is she going to fare better if we're treating her disease? You know, if she has, if she's going into a pregnancy with type 2 diabetes or prediabetes, or she now has developed gestational diabetes, would it be better to treat her with a GLP-1?

1:33:38Will they run those trials, do you think? Because like from an ethical point of view, do you think they'll randomize women to a GLP-1 versus a placebo during pregnancy? If we ever have that in the future, I mean, I think that potentially that would come after having a very large amount of retroactive observational data where we have ensured thousands and thousands and thousands and thousands of women have been observed and like we didn't have any outcomes that were negative. Then maybe we do randomize. But is that likely to occur if women who become pregnant are being told to stop their GLP-1.

1:34:19Yeah, I know, right? It's really hard to study. Because right now, if you have a woman that comes into your clinic that does get pregnant, are you telling them to come off? Oh, totally. Like a two-month washout period prior to. And I'm following what the FDA recommends for me to counsel on as well. And until I have more safety data as an evidence-driven physician, I will not sit across from my patient with a good heart and tell her that's safe. Two-month washout, meaning two months, that's if you have the opportunity to plan. Yeah, right. So if you're planning, try and stop the GLP-1 two months before you start.

1:34:53Yeah, yeah, yeah. For conception, yes. And then if someone just gets pregnant without money, you stop straight away. Yeah, that's like similar to, oh, I'm on my Adderall medication, I'm taking Adderall, and you're pregnant. Or like, oh, you're an autoimmune disease and you're on, you know, something biologic. Is there any evidence that GLP-1s improve PMOS independent of body weight? So PMOS, I think of, I'm treating twofold. It's not just a reproductive problem, it's also a metabolic concern. And so how do I treat metabolic disease at all? I'm looking at the typical parameters, right? Her A1C, her lipids, like her blood pressure.

1:35:35And so if I'm treating her PMOS, Let's backtrack as well as define PMOS in case someone thinks we're speaking in different languages. Oh, yeah. Polycystic ovarian and metabolic syndrome. And it is diagnosed classically by the Rotterdam criteria, two of three. And that diagnosis criteria is under review and is likely also expanding. But for now, that's what it is. And it's a two-part disease in my mind. One is the very classic presentation of infertility, and that is oftentimes taught in medical schools is that it's a disease of infertility. And the second part that is equally as important for her whole person health is the metabolic piece, is that there's an insulin resistance.

1:36:26And that is on, that's at the genetic receptor level. The high testosterone or preferential testosterone production is thought to be from the pulsatility of the DNRH pulsatility coming from the hypothalamus being too fast. And so that's what's understood of PMOS right now. And that needs more research and we haven't researched that enough. But in understanding that insulin resistance is an underlying driving process for PMOS, it makes perfect sense for me to use a GLP-1, which literally helps her pancreas make more insulin and sensitize her to the insulin that she does make. What if she is not overweight?

1:37:08Oh, great question. So I have found in clinical practice, and it is true, that one drives the other. And what do I mean by that? high insulin can drive high testosterone. So if I'm still having someone of, let's say the phenotype is what we say. So like their physical exam has hirsutism. So she's having high signs clinically of testosterone. She's having acne and body hair that is incongruent with her, you know, gender or how she feels about it. Then I'm putting her on maybe not necessarily something like a GLP-1 because it might lead her to have too much weight loss if she doesn't need weight loss, but putting her on something like metformin would be perfect.

1:37:50And I have seen, you know, in addition to starting her on spironolactone, which blocks androgens at the receptor and helps with androgenic alopecia hair loss, helps with acne, putting someone on metformin and sensitizing to her insulin also helps lower inflammation and lower testosterone. Is metformin the best drug for insulin resistance? It's a gel-boid. Are there other drugs? I think it's GLP-1. You think GLP-1's for insulin resistance? Yeah, yeah, yeah. So, like, if you, I just take people off their metformin if they're, like, if I can accomplish controlling your condition based off of A1C parameters and, like, total, like, functional mobility, everything like that, and we're just on a GLP-1, why would I have you on metformin?

1:38:34Are there any other drugs that improve insulin resistance? Well, I was going to say earlier that, you know, what are the two most revolutionary classes of medications? I would say there's probably the GLP-1s and the statins right so like my like the doctors who are 30 years older than me are like I remember when statins came out again a joke but I would add to that also the SGLT2 inhibitor class SGLT2 inhibitor class my all the nephrologists are freaking out listening to this but they love that so like the I have uh is it Ralph DeFronzo I don't know if you've ever heard of him I don't know he actually came up with the whole SGLT2 inhibitors.

1:39:11Oh my God, that's crazy. Yeah. That's so cool. He's coming on the show soon. He's coming on the show soon? Wow. Tell him I think he's cool. He's like a legend of type 2 diabetes. No, he's a legend. Everyone listening to this is like, she doesn't know who he is. That's really embarrassing. No. Well, I mean, you would be familiar with his research and also the guidelines are completely affected by his research. It's just his name on the paper that, I mean, a lot of people are probably not familiar. Well, look at me. I brought it up myself. I brought SGLT2 inhibitors myself. Exactly. And so like there's literally a morbidity mortality benefit for people who have chronic kidney disease and heart failure.

1:39:45And so we put people on SGLT2 inhibitors who have heart failure with preserved ejection fraction and it helps them like helps people keep people out of the hospital. And so I would say that SGLT2 inhibitors help you excrete more sugar in the kidney. So that's why one of, you know, one of the side effects is like increased like candidal infections or bacterial infections, like urinary tract infections. I would beg to differ and say, is she even on vaginal estrogen? Don't stop the SGLT2 inhibitor. By helping you excrete more sugar, you're helping lower your constant production of insulin. So that's, I would say SGLT2 inhibitors also are pretty revolutionary.

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1:41:26Do you ever consider, and this is stepping outside, I guess, clinical trials and perhaps guidelines for someone with PMOS that doesn't need to lose weight, like a microdose, a lower dose of trisepatide? Yeah. We've never studied that, but that would make sense to me. That would be really cool. Can you do that clinically? Are you allowed to prescribe kind of outside of the guidelines for contexts that don't perfectly fit? I usually don't prescribe if their BMI isn't around 27 with like a weight related comorbidity. I would say, and look, we're using the word BMI, right? Because we're in the insurance-based system or we're operating with BMI.

1:42:05But I would say that if we have a normal weight, like let's say someone's like BMI is 23 or something, and her losing 10 pounds would be like too significant. Right now with the GLP ones we have, I wouldn't start her on terzapatide or some inglutide because the potential for weight loss there is maybe too strong. It's too much. And that probably might not even help this patient. With the other medications that we have now, let's say Foundio in clinical trials, it was around 11 % weight loss. That would be a better choice for her if she is overweight and she has PMOS. That's an oral. That's the oral daily.

1:42:47Yeah, the GLP-1 molecule. That's the daily medication from Lily. So then knowing that the maximum total potential could be 11 % of her body weight loss, I might choose that for her because turns out I'd be too strong. What other things do you do personally with your lifestyle to help manage PMOS? I work out. I think that's life-changing. I do a lot of Pilates. I have a relationship. I tell my patients about my relationship with Pilates. It's like you give and you get back. That's what a relationship is, right? And so showing up three times a week and doing Pilates and doing that for months and months and months and months and months has been like incredibly rewarding.

1:43:29I get into it with the gym bros online. I don't understand what they're talking about when they're saying that Pilates doesn't increase your muscle mass. Like that just doesn't make any sense. Like you can't say that Pilates doesn't help your physiology. It's a very well-known bodybuilder, PhD person who says, word for word, Pilates doesn't help your physiology on the internet. Not really sure why. Do you understand why? I think sometimes people speak in absolutes when it's not accurate. I mean, I think a more accurate... Firstly, when you just said there you do Pilates three times a week, I think of that and it sounds like absolute torture to me because if you haven't done Pilates, go and do one, you'll be absolutely dead by the end of it.

1:44:12Yeah, but now you're good. But then you become good at it. Yes, like you become good. but particularly my male friends that go into Pilates, we struggle. I do think it's a great workout. I think that Pilates has enormous health benefits and you're going to get stronger and your core is going to be strong and it's going to be good for mental health. Where I think those statements come from, perhaps people that are kind of over-indexing, thinking about something like bone density. And yes, best evidence-based practice for bone density would be doing impact training or like some heavy resistance training, but you can do both.

1:44:51And Pilates, just because Pilates isn't, its primary benefit isn't necessarily bone density doesn't mean it's a bad workout and it doesn't have benefits. No, totally. And I don't lift that much. And like, look. Totally. And some of the strongest people I know are people that do Pilates and yoga religiously, and they're not in the gym lifting a lot of weights, yet their ability to use, like lift their body weight is much better than people that I know that are in the gym lifting a lot of weights and also their mobility and ability to navigate their environments better. So actually think personally, if again, we come back to longevity, I don't think you want to over-index in any one.

1:45:35I think it's good to have a variety, like you move your body in different ways. But most importantly, like your face lit up when you talked about Pilates. Find the thing that you like and that you want to turn up to and that, you know, is fun for you. And, you know, if you do it with friends and there's a social element, even better. Totally. I agree. Okay. You mentioned before body fat distribution and menopause. Yes. I think that something that I certainly get asked a lot about and I think is really common, this experience of a woman that goes through menopause, she notices that she might be carrying a little bit more weight around the midsection and also maybe got a blood work done and things are not the same as they were 30 years prior.

1:46:22Totally. I'm sure this is a kind of avatar that you would see all the time. All the time. And it comes down to what do we have evidence for? And we need to have integrity about what do we not have evidence to say is happening. So when we go through menopause and every woman goes through it at some point. The changes in hormones drive appetite and change the way that you store fat on your body, okay? That is what we have the evidence to say. We don't have the evidence to say that because you're going through menopause, your metabolism is slowing down. We don't have that evidence. We do have the evidence to say that metabolism slows down generally with aging, and it does that for everybody, any gender, after 60 years old.

1:47:16But the conversation that I'm trying to be really specific and careful about is the menopause conversation right now. And it's giving her the power and the tools to understand, And yes, my hormones are changing. Hormone replacement therapy should be an option for me. But hormone replacement therapy is not used for weight loss. And I'm not gaining weight in menopause because my metabolism is slowing down. I don't want her to walk out of the room and think that at all. I want her to walk out of the room and feel empowered with the knowledge. My hormones are changing. I'm storing fat differently.

1:47:53the quality of life I'm currently living with like hot flashes and also just like the social responsibility and burdens on women in that stage of their life. They're usually taking care of everyone younger than them. You know, 45 year old woman, 50 year old woman is taking care of the generations younger and all of the generations older. She is the glue of the family. So in addition to that, you know, she's having, she's having hot flashes and, you know, she's not able to get herself to the gym and make the best decisions about her diet. So when it comes to the menopause conversation, women deserve to know what do we have evidence for and what do we not have evidence for.

1:48:24But I also think that I belong to this school of thought that women can't sit around and wait for evidence to happen either. So we can't have the perfect evidence all the time. I think it's very paternalistic to take away options from women because we don't have evidence. They should be able to have all of the options in front of them. And I should be able to say, no, I don't have the cardiovascular disease data on long-term testosterone therapy, but if you have hypoactive sexual desire disorder and you would like to try testosterone therapy and you're okay with having cardiovascular risks to that, that is in your power to do that.

1:48:59Like, I'm not here to take that option away from you. Everyone should have all their options. So what are the most common interventions, pieces of advice that you lean on clinically that you see are providing benefit to this population? The backbone of therapy for menopause is hormone replacement therapy, and that is estradiol. And that is done through a transdermal patch because you're bypassing the GI system, you're bypassing the portal system, you're not activating the clotting factors in the liver. So why would I have a risk for, you know, like a clot when I don't need one? And what are the short-term slash long-term benefits of that?

1:49:36There's a silent benefit that we don't talk about enough, and that's osteoporosis prevention. and I do this a lot with my patients who have osteopenia and I want them to know that there is an option to be on estradiol transdermal patch and if you have a uterus you also have to be on micronized progesterone you can also have an IUD that's progesterone but you just need uterine protection but I just want women to know that even if you're not suffering from like catastrophic hot flashes I just want you to know that there is the option out there that giving women back estrogen also prevents osteoporosis or slows down the development of osteoporosis.

1:50:11So there's that benefit as well. What women in that population are contraindicated for estrogen? So I'm a family doctor and I think that hormone replacement therapy should be bread and butter for primary care. Half of our patients are women, if not whatever, they all go through menopause. The second you have had a, let's say, hormone positive cancer, that is not bread and butter anymore. We need to have a conversation about what is the risk that we're aware of and what is the risk we're not aware of. That is when I lean on my menopause specialist colleagues, for sure. Like an oncologist or something?

1:50:48Totally. Or I have someone who did OBGYN residency and then has really dedicated their life to menopause and all of the intricacies and nuances. Not everyone with breast cancer can't have an estrogen patch. That's not true at all. Sometimes that wasn't even a hormone positive cancer and it was an exposure cancer. and it happened to their mom when they were much older why would that preclude her from being on an estrogen patch that doesn't make any sense but back in the day back in the day five years ago people weren't even given the option oh you have a one degree relative who had breast cancer you can't have a patch that's crazy and what do you think about the change in in body composition uh-huh so you mentioned that you have a decrease in estrogen and like a relative increase in testosterone and it increases your visceral adiposity.

1:51:38Does the use of estrogen affect that? We have a study, like they studied women going like prior to going into menopause who were on HRT and those who weren't. And there was a significantly different, you know, statistically significant difference in visceral adiposity between those two populations. I just don't have enough data to say like, if you start HRT like prior to going through the change. It's going to completely avoid putting down visceral adiposity in this way. I don't have the evidence for that. So what else could a woman lean on or do that is experiencing increased abdominal waste adiposity and is worried about their cardiometabolic risk or they're worried from an aesthetic point of view?

1:52:25It has everything to do with your overall health, which has always mattered. So it has everything to do with, are you strength training? What are you putting in your body? Or we go into a conversation of energy balance. I have that conversation with people all the time. My brain likes to make things objective, then I just kind of understand them. And so if I'm in an energy surplus for the day, that has to go to storage. If I'm in an energy deficit, my body is going to go scavenging for energy. I always talk about that. I talk about your muscle mass. I call it your metabolic sink. I have learned muscle mass to be called that myself.

1:53:03Like I, that's just how I understand it too. You know, like I, and I use the example all the time, like me and Michael Phelps are eating the same meal. His metabolic sink is massive. His muscles are going to see glucose in his bloodstream and go, I need more. Mine's going to spill over and be like, girl, your metabolic sink is a glass of water. Like his is an Olympic swimming pool, you know, that all has to do with how much muscle mass you have. And so when I explain to patients how you process sugar, how you process cholesterol, and why are we putting on visceral weight here or adiposity here, I go back to what is your metabolic sink?

1:53:39What's your ability for your liver and your muscles to process what you're eating? And that it's just worsening in this period of life, and it's just more prominent. But go back to basics. We're having all the same conversations, right? Lift weights, eat enough protein and fiber, and eat healthy fats, have a largely Mediterranean diet, get enough sleep, have a sense of community, you know, work on intimate relationships, a feeling of self-fulfillment in your life. It's about overall wellness. Are you using GLP-1s in this population? Oh, yeah, for sure. Especially if they do have obesity or if they are overweight.

1:54:18I think that with an increase in appetite and an increase in adiposity, you get inflammation and increase in excess adiposity drives hunger in and of itself. And so when women, and they're already at an increased cardiometabolic risk, when we're looking at observational data of women in this age range or in this age group, the cardiovascular risk is already elevated for women who are going through menopause. So if I have a patient sitting in front of me, I'm looking at her weight trajectory. It's just going up. Her metabolic parameters are worsening. It's almost like, why wouldn't I catch her now?

1:54:56Why wouldn't I give her the help? And she's also looking at you and she's asking you for help. Like, and you, with everything that you know as a doctor, how could you just look at her and be like, no. What should a woman in her forties or fifties, who you mentioned earlier, I think a lot of this population. They're looking after the younger generation. They're looking after the older generation. But they do get to a point in their life often when the younger generation has moved out. And all of a sudden, they do have a bit more time to focus on themselves. And they're like, wow, I've been caring for everyone else for the last 20 years and put their health on the side.

1:55:34And now they're really interested in how they can live a healthy life. What are the top things that you think they should be measuring and aware of in their body? And what are the things that maybe they're being sold online that that's BS or a distraction? I need everyone to know their cholesterol. Everybody needs to know what their lipids are, right? And so you will have an average conversation with a 45-year-old woman and she'll just tell you, oh, my family doctor, oh, I've always had high cholesterol. My LDL has been 130 for years. It's in my 20s. She's been living with an LDL of 140 for 20 years, and that's not casual.

1:56:14Or you have a conversation with another 40, whatever, seven-year-old in her A1C is 5 '6". I don't care that it's 5 '6". That is 0.1 under 5 '7". That is almost prediabetes. And maybe one time it was 5 '7", and it's been just chilling around 5 '6 for years. You know? Those are the silent killers. When we make things casual and we're not proactive about them. And the combination of the fact that she has heart disease in her family, she has low underlying, maybe subclinical prediabetes. You combine that with like an LDL that, you know, was over a hundred for like the past two decades. This is all what's like building what we actually care about, which is the outcomes we care about, like the heart attack she's going to have at 65.

1:57:01Or the cognitive issues. Or the cognitive issues or risk for dementia for her, like later down the road. And so it's about being a family doctor. It's about being proactive and catching those little clues and putting it all together for her as a whole person. Are there any tests that you see diagnostics or other things marketed towards women going through menopause that you think are just a waste of time? Yeah, I do. So like you don't need to spend as much money as everyone is spending. You don't need to have a fancy marketed pink creatine women's creatine yeah yeah what what creatine monohydrate is creatine monohydrate like what's going on um you don't need to have like it's in a pink tub yeah right no like someone reached out to me for a brand deal for that it was thought it was so funny it was like a women's creatine company it was like a pink pete i'm not gonna say the brand sorry can you cut that out or a bunch of like protein fiber supplements like all the supplements i'm like what's going on why are we doing supplements we can do prescriptions and we can go you know do the basics of health which is lifting weights and sleeping well and if you need pharmacotherapy and that's evidence-based then go talk to a physician do not go and get a menopause supplement where you don't know what's in it with a bunch of like ashwagandha lion's mane a bunch of stuff i don't know that that is such there's such a market for that for like hormone balancing for hormone balancing even like you know the same thing like the whole thyroid world the whole thyroid balancing world which i have recently discovered like oh my gosh there's a whole like menopause there's almost something for every organ there's adrenals oh yeah yeah yeah But it's so funny because people only think the adrenals make cortisol.

1:58:44Do they wait till they discover all the other things the adrenals do? You have strong views. I like that. Yeah, you're opinionated. You're not scared to have an opinion. Do you ever find that that repels people or gets people in the back foot? Yeah, I would say that I naturally feel very strongly about certain issues. And that's before I ever had a presence online. I'm just like that. And I will always be a proponent of like women's reproductive access and freedom. I will always be a proponent against like mass incarceration of children and using police brutality. Like I'm just describing the things happening in America right now.

1:59:26And I will never be quiet about those things. and because you love your country, you feel invested and wanting the best for it and wanting things to change. And I communicate that online a lot. And I think people see that, but I think a lot of other people, the internet is a terrible place for nuance because you can't explain everything. And so someone will be like, oh, I saw your video that you don't want to make America healthy again. No, I said they make America healthy again. Movement is not making America healthy again. You know, you don't make America healthy again by putting push-up bars in airports or whatever they did.

2:00:02You try to fund the healthcare system. When was America truly healthy? I don't know. Much more. Because I think people point back to the 1950s, but forget that cardiovascular disease, heart attacks, and strokes were quite prevalent and increasing. Yeah. Well, it's like when make America great again. Again, for who? how do you balance having a very strong opinion on something which i think is a i think it's i think that's very admirable it's a trait that i like when i see that someone's willing to put a stake in the ground and have an opinion how do you balance that with

2:00:46not being overcome with emotion to the point that you can't change your position and stay open-minded, particularly in the context of science? I usually feel really passionate about things that I'll probably never change my mind about, which is human rights and funding scientific research and freedom of speech. I will never not support those things or feel passionate about those things. So if the topic is newborn happy vaccinations, knowing what we know about the incredible efforts across the world by the WHO and everything that we have lowered HEPI across the world. And, you know, the misinformation being spread about it being bad for newborns in the U.S.

2:01:28So that is just pure misinformation. And if I post a video about, you know, your government is lying to you, if I watch that video in the future, I'm never not going to, you know, stand by that. We know the evidence surrounding HEPI vaccine. We know how important that is. We know how, like how terrible chronic FB is and how we can't cure it and how deadly it is. And so as long as you can stand to the fundamental basics, like you stood for civil rights, you stood for the truth in what you believe, then go for it. I also think you need to stand for something in this life. I also get people asking me all the time, how do you feel so confident being so outspoken politically and i don't understand how you people aren't like i like truly that's not supposed to be smart or anything like that well i think it's a it's it speaks to a level of resilience that you have because for many the fear of when you take a strong opinion thing is you're going to have a lot lot of people that side with you and agree with you, but you're also going to have a lot of people that disagree, right?

2:02:42That's just naturally what happens when you don't sit on the fence. Okay. So the people that disagree with me don't want to fund healthcare access. They're not my friends. Right. So I think, again, that speaks to a level of resilience that you've cultivated at some point in your life. I'm also an immigrant. I think that comes down to it, being an immigrant. You have to got to be tough if you're like, other than like coming to the US as an immigrant, I think anyone listening to this can relate to that. You're an immigrant. Were you born here? I was born in Australia. You're born in Australia. Well, I was born in Sweden.

2:03:13Yeah. I've actually never really considered myself an immigrant. You've never considered yourself an immigrant? Oh, interesting. Well, I think culturally, because I spent eight years here when I was a kid, I feel very connected to both America and Australia. Very cool. Me too. I feel more connected to the U.S. actually because I actually was raised in the U.S. Like I moved here when I was eight. But anyway. But I'm proudly an immigrant because you still have this whole experience of other than that you have to get through. Like coming to the U.S. not speaking perfect English, being in a separate, like, I guess you already spoke English when you came here.

2:03:44That's different. That's a little different. I think, like, not understanding the language, having to learn a new language, all those things, makes you very resilient. I also think it depends, like, where you have immigrated from and, like, what's the perception. like i i candidly haven't i think experienced like racism or felt like a minority that others could feel totally and i said that about um erling haaland i was like he's having a great time in america because he's a white viking and americans are fine with that but if you look at the way mbappe was treated when he is on his like on the world cup tour he's getting racist tweets at him and he's a black player.

2:04:30And so you can be like a multi-millionaire world famous soccer player. And the only difference is one is white and one is black. One will experience racism and one won't. And that's true for the immigrant experience. Like I pass for a white American girl and I have said that. And I also speak like one. And so I have not had to go through what other immigrants have to go through who don't get to pass for a white American girl. And that's just the way it is. What would you say is the most frustrating thing that's been brought to your attention on TikTok or Instagram, social media recently, related to your job as a family medicine obesity specialist?

2:05:10That Maha movement took credit for improvement in America's obesity rate. That was really crazy. Are they pro-GLP ones? They're not. They're pro, like, you know, try more, like better lifestyle, work out more, eat better. That was the entire, that's the entire messaging for making America healthy. Again, it's all about physical exercise. Hasn't Trump made the GLP ones more accessible or is that not true? So he didn't lower the price of GLP ones. They are the same price that Eli Lilly had already established at their direct-to-consumer pharmacy. It is just more accessible now through the TrumpRx website.

2:05:51and that is a federal website. So of course, everyone's going to hear about it. So he's basically just like, here's the$500 price, but you can also just go get that price at Lily Direct, is what I'm trying to say. And he also worked with Mark Cuban to integrate their formulators for Cost Plus Direct. So now everyone's working together, which is a good thing. Why wouldn't you want people working together? That's what I mean by feeling confident and being political as a physician is that health is always political as long as health is not guaranteed by your government. If you live in a country where your government can defund your health care system to the point where you don't even think, like, where is it?

2:06:28What is Medicaid? What is Medicare? Are those offices? Do people work there? You know what I mean? Are those buildings in D.C.? Because they're not. They used to be bigger institutions and have, like, staff and everything, but they've been defunded. We don't have, like, those aren't big offices. The Office of Medicaid, the Office of Medicare. So anyway, when your government is always coming after the health care infrastructure and access for the people that you're always taking care of, health is always inevitably political. What it is never, and Dr. Mike said this on TV recently and I loved it, was health is always political, but it's never bipartisan.

2:07:02And I love saying that because you know who I mostly took care of in residency? That was in the Shenandoah. Those people are all on Medicaid and they all vote red. this is the way it is that like they're all republicans i don't care who what political party you belong to i don't literally don't care like you're sitting in front of me your political party doesn't matter i will take care of you but when we're talking about systems issues like funding the health care system that's inevitably political so what's the medical health care system world that you want to see if we're having if you and i were sitting down in 20 years and everything, let's say, goes to plan according to what you think would shift the needle the most.

2:07:46What's the world that you're living in as a family medicine physician then? If you spoke to me like six months ago, I would have said universal healthcare, like single-payer system, universal healthcare. I would want it to be like several European countries. There's a lot of issues with single-payer systems, like the wait lines and resource allotment and like just the emergency weight rooms like in Canada, for example. But what is a realistic answer is what do we have right now and what do we do with it? We need to regulate what we have. We're not going to just throw it away. Like we're not going to just burn it down to the ground and create a single pair universal healthcare system.

2:08:29That's not American, right? Things in America only happen if the money makes sense. We need to flow money into something that actually makes sense. We need to regulate the current market. We need to create a free market again. It is not a free market. It is a total monopoly by like three companies, UnitedHealthcare, CDS, Express Scripts, and they have created vertical integration systems where they control the price point every step of the way. They want to own the PBM that resets the rebates, that renegotiates the rebates. They want to own the pharmacy that sells the drug. They want to own the insurance company that sets the plans and decides the employment benefits with all of the corporations that offer the health plans.

2:09:12They own every step of the process. They want to own medical clinics. They want to employ physicians. UnitedHealth Group started a bank to hand out loans to people who are running into debt from their insurance company, a loan with an interest straight tacked on that goes back to the parent company. Like, why does an insurance company need to create a bank? Too few people with too much control. Exactly. So it's like end stage capitalism. Everyone's now it's a monopoly. We allowed for healthy competition. CVS won. Good job. United Health Group won as well. Express Scripts also won. What do you think someone would push back on if there was someone here sitting here that disagreed with that and said that that won't works.

2:09:56Yeah, like someone who's like way smarter than me and has like a whole plan. That would be, I talked to Elizabeth Potter about that. I talked to, she has, she's so smart. I love her. And then if you, if you listen to Mark Cuban talk about it, he's so smart. Love him. And what do they talk about? They talk about break up the vertical integration structures, regulate them. Don't allow an insurance company to own a hospital clinic. There is obviously a conflict of interest. There's obviously a conflict of interest. Next is transparent pricing. Why are they not forced to show us what the rebate deals were?

2:10:32They don't have to tell us how much money Novo gave them to prioritize their medication. That's not a transparent deal. That's a backroom deal. No one knows how much money they get. What else? There's so much more. Get rid of PBMs altogether. We don't need them. They were created as entities out of thin air to be middlemen to have the opportunity to hijack prices. Just get rid of them. Go around them. Create more pharmacies like Cost Plus Drugs that buys directly from manufacturers. We need to create an entire ecosystem just like Cost Plus Drugs. Okay, love Cost Plus Drugs, but we need like a thousand more of them so that there is a new ecosystem where we operate with them who just go to manufacturers and they sell directly to consumers.

2:11:14Much cleaner. totally gets rid of all of this bureaucratic bloat stuff with the PBMs. So what do we need to do? Break up the vertical integration systems, get rid of the PBMs, just create transparent prices. We need hospitals. And it's not just about the insurance companies. It's also about hospitals. Hospitals are not transparent with what they're billing. So for example, the surgeon that did your surgery gets paid$1 ,000 for the surgery they did. The facility fee is$40 ,000. so your bill ends up being$50 ,000 but$1 ,000 went to the doctor everything else went to facility fees and all these other things and then what are you going to do you're going to ask for an itemized bill from your hospital stay and you're going to go through that individually and you're going to ask them to go through it and the number of times I've had patients that have had mistakes on their hospital bill and saved money because they asked for a patient advocate those are the magic words if you're in the hospital.

2:12:11I need a patient advocate and I want an itemized bill of my stay. If you just had a hospital stay and it's ridiculously expensive, you're going to ask for those two things. You're going to go through it. Well, this has been awesome. I love your passion. Thank you for coming and hanging out with me. Yeah. Thanks for having me. You've got a full stack of drinks there on the table. Yeah. Thank you so much. Thank you. There you have it, friends. I hope you enjoyed this episode. If you did and want to stay up to date with future episodes, be sure to hit that subscribe button on YouTube and follow on Apple or Spotify.

2:12:45Finally, thank you for showing up and the effort that you're making to take control of your health. I look forward to hanging out with you again in the next episode.